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I. Patient Information II. Individual/Organization Authorized to Release (California)

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STATE OF CALIFORNIA
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
CDCR 7385 (Rev. 10/19)
DEPARTMENT OF CORRECTIONS AND REHABILITATION
Form: Page 1 of 2
Instructions: Pages 3 & 4
All sections must be completed for the authorization to be honored. Use "N/A" if not applicable.
I. Patient Information
Last Name:
First Name:
Middle Name:
CDCR#
Date of Birth:
Street Address:
City/State/Zip:
II. Individual/Organization Authorized to Release Personal Health Records if Other Than CDCR
Name:
Address:
City/State/Zip:
III. Individual/Organization to Receive the Information
[45 C.F.R. § 164.508(c)(1)(ii), (iii) & Civ. Code § 56.11(e), (f)]
The undersigned hereby authorizes CDCR's Health Information Management to release the health information pursuant to this authorization.
Name:
Relationship to Patient:
Phone:
Fax:
Address:
City/State/Zip:
IV. Authorization Expiration Event or Expiration Date for Release of Verbal Information/
Written Correspondence
[45 C.F.R. § 164.508(c)(1)(v) & Civ. Code § 56.11(h)]
Unless otherwise revoked by the patient, this authorization for the release of health care information to the above-named
individual/organization will expire on the date specified below, event identified, or 12 months from the date signed in Section IX,
whichever occurs first:
Date of Expiration:
Event:
From (mm/dd/yyyy): To (mm/dd/yyyy):
V. Health Care Records to be Released - General
[45 C.F.R. § 164.508(c)(1)(i) & Civ. Code § 56.11(d), (g)]
I authorize records for the following period of time to be released (must be completed to receive records):
From (mm/dd/yyyy): To (mm/dd/yyyy):
Medical Services
Dental Services
Other:
NOTE: Health records released as part of this authorization may contain references related to mental health, substance use disorder,
medication assisted treatment, genetic testing, communicable disease, and HIV medical conditions.
VI. Health Records to be Released - Specify
[45 C.F.R. § 164.508(c)(1)(i) & Civ. Code § 56.11(d), (g)]
Communicable Disease Records
from
to
Signature:
Date:
Genetic Testing Records
from
to
Signature:
Date:
HIV Test Results
from
to
Signature:
Date:
Medication Assisted Treatment Records
from
to
Signature:
Date:
Mental Health Treatment Records
from
to
Signature:
Date:
Substance Substance Use Use Disorder Disorder Records Records
from
to
Signature:
Date:
NOTE: Health records released as part of this authorization may contain references related to dental, medical, mental health, substance use
disorder, medication assisted treatment, genetic testing, communicable disease, and HIV conditions.
Requests for psychotherapy notes require a separate CDCR 7385 and may not be combined with any other request for health records.
Psychotherapy Notes
Unauthorized collection, creation, use, disclosure, modification or destruction of personally identifiable information and/or
protected health information may subject individuals to civil liability under applicable federal and state laws.
DEPARTMENT OF CORRECTIONS AND REHABILITATION
Form: Page 2 of 2
Instructions: Pages 3 & 4
4
All sections must be completed for the authorization to be honored. Use "N/A" if not applicable.
VII. Purpose for the Release or Use of the Information
[45 C.F.R. § 164.508(c)(1)(iv)]
STATE OF CALIFORNIA
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
CDCR 7385 (Rev. 10/19)
Health Care
Personal Use
Legal
Other (please specify):
VIII. Authorization Information
I understand the following:
1.
I authorize the use or disclosure of my individually identifiable protected health information as described
above for the purpose listed. I understand this authorization is voluntary.
________________________________________
2.
I have the right to revoke this authorization. To do so I understand I can submit my request in writing to
my current institution's Health Information Management (health records). The authorization will stop further
release of my protected health information on the date my valid revocation request is received by Health
Information Management. [45 C.F.R. § 164.508(c)(2)(i)]
3.
I am signing this authorization voluntarily and understand that my health care treatment will not be
affected if I do not sign this authorization. [45 C.F.R. § 164.508(c)(2)(ii)]
4.
Under California law, the recipient of the protected health information under the authorization is
prohibited from re-disclosing the protected health information, except with a written authorization or as
specifically required or permitted by law. [Civ. Code § 56.13]
5.
If the organization or person I have authorized to receive the protected health information is not a health
plan or health care provider, the released information may no longer be protected by federal and state
privacy regulations.[45 C.F.R. § 164.524(a)(2)(v)]
6.
I have the right to receive a copy of this authorization. [45 C.F.R. § 164.508(c)(4) & Civ. Code § 56.11(i)]
7.
Reasonable fees may be charged to cover the cost of copying and postage related to releasing this
protected health information. [45 C.F.R. § 164.524(c)(4) et seq. & California Health and Safety Code §
123110, et seq.]
8.
I understand that my substance use disorder records are protected under the federal regulations
governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R., Part 2, and the Health
Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. pts 160 & 164, and cannot be
redisclosed without my written consent unless otherwise provided for by the regulations.
IX. Patient Signature
[45 C.F.R. § 164.508(c)(1)(vi) & Civ. Code § 56.11(c)(1)]
Name: (Print):
Signature:
Date:
If no expiration date is specified in section IV, this authorization will expire 12 months from this date.
Name of person signing form, if not patient (Print):
Signature:
Date:
Describe authority to sign form on behalf of patient:
Name of translator/interpreter assisting patient, if applicable (Print):
Signature of translator/interpreter:
Date:
Unauthorized collection, creation, use, disclosure, modification or destruction of personally identifiable information and/or
protected health information may subject individuals to civil liability under applicable federal and state laws.
STATE OF CALIFORNIA
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
CDCR 7385 (Rev. 10/19)
DEPARTMENT OF CORRECTIONS AND REHABILITATION
Instructions
Note: Part IV is the request for release of verbal health care information or health care information as part
of written correspondence, and Part V is the request for release of health care records.
Part I - “Patient Information”: Records the patient's full name (last, first, and middle), CDCR number, date of birth,
and address if he/she is paroled or released (incarcerated patients do not need to provide an address).
Part II - "Individual/Organization Authorized to Release Personal Health Records if Other Than CDCR":
Records the name and address of the individual or organization authorized to release personal health records if
other than CDCR.
Part III - "Individual/Organization to Receive the Information": Records who is to receive the information.
Part IV - "Authorization Expiration Event or Expiration Date for Release of Verbal Information/Written
Correspondence": Used by the patient to limit the time period during which information may be shared.
• The patient may enter the date he/she wants the authoriz
ation to expire.
• The patient may enter
an expiration event.
• The patient may enter a date range of
information to be shared.
• If no expiration date is specified, t
his authorization is good for 12 months
f
r
om the date signed
in Section IX.
Part V - “Health Care Records to be Released
- General
”:
Contains
a designated line for the date range of health
care records to be released.
• “Medical Services” is checked when the patient wishes to have information released related to medical care.
• “Dental Services” is checked when the patient wishes to have information released related to dental treatment.
• “Other” is checked when the patient wishes to further restrict or further authorize the release of his/her medical
information, and he/she is to write those wishes on the line provided.
•
•
•
•
•
•
•
Part VI - "Health Records to be Released - Specify": Health c
are information in
this section requires a date range,
additional signature, and signature date.
• “Communicable Disease” is checked when the patient wishes to have information released related to
communicable disease testing and treatment. Communicable disease includes sexually transmitted infections.
• “Genetic Testing” is checked when the patient wishes to have information released related to genetic testing.
• “HIV Test Results” is checked when the patient wishes to have HIV test results released.
• “Medication Assisted Treatment
Records” is checked when the patient wishes to have information related
to medication assisted treatment released.
• “Mental Health Treatment Records” is checked when the patient wishes to have information released
related to mental health treatment.
• “
Substance Use Disorder Records” is checked when the patient wishes to have information related to
substance use disorder treatment released.
• “Psychotherapy Notes” is checked when the patient wishes to have psychotherapy notes released.
Requests for psychotherapy notes require a separate CDCR 7385 and may not be combined with any
other request for health care records.
Under HIPAA, there is a difference between regular personal health information and psychotherapy notes. The following
is HIPAA's definition of psychotherapy notes (§164.501):
Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a
mental health
professional documenting or analyzing the contents of conversation during a private counseling session or a group,
joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy
notes excludes medication prescription and monitoring, counseling session start and stop times, the
modalities and
frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis,
functional status, the treatment plan, symptoms, prognosis, and progress to date.
Unauthorized collection, creation, use, disclosure, modification or destruction of personally identifiable information and/or
protected health information may subject individuals to civil liability under applicable federal and state laws.
STATE OF CALIFORNIA
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
CDCR 7385 (Rev. 10/19)
DEPARTMENT OF CORRECTIONS AND REHABILITATION
Instructions (continued)
Part VII - “Purpose for the Release or Use of the Information”: Should have at least one box checked. The patient
may utilize this section to check the provided boxes or select “Other” and describe the reason(s) he/she
wants to have the information released. If the patient does not want to designate a purpose, he/she may
check the “Other” and state “At the request of the individual authorizing the release.”
Part VIII - “Authorization Information”: Below this section are eight points which detail patient rights in regards
to authorizing release of information.
1. Tells the patient that he/she is giving authorization voluntarily.
2. Explains how to stop this authorization. The patient may revoke the authorization by submitting his/
her request in writing to his/her institution's Health Information Management. The
authorization will be removed from the patient's medical record when the revocation is
received by Health Information Management.
3. Explains that signing this authorization is voluntary and will not affect treatment.
4. Explains that the recipient of the protected health care information under the authorization is
prohibited from re- disclosing the information, except with a written authorization from the patient or as
specifically required under law.
5. Explains that the released information may no longer be protected by federal privacy
regulations depending on the intended recipient of the released information.
6. Explains that the patient has the right to receive a copy of this authorization. This will be sent to
the patient by Health Information Management.
7. Explains that reasonable fees may be charged to cover copying and postage costs related
to releasing the patient's health information.
8. Explains that substance use disorder records are protected and cannot be disclosed without the
patient's written consent unless otherwise provided for by the regulations.
Part IX - “Patient Signature”: The bottom of page two is for the patient's, his/her representative's, or the
translator/interpreter's signature. The
patient's printed name, signature, and date are to be entered in the
boxes provided. If this authorization is completed by a patient representative (e.g., power of attorney,
estate representative, next of kin), his/her printed name, relationship to patient, signature, and date are to
be entered in the boxes provided. Also attached must be a copy of either the Power of Attorney, letters
issued in estate proceeding, or declaration of next of kin. If an interpreter/translator assisted the patient in
filling out this form, his/her printed name, signature, and da
te are to be entered in the boxes provided.
Unauthorized collection, creation, use, disclosure, modification or destruction of personally identifiable information and/or
protected health information may subject individuals to civil liability under applicable federal and state laws.
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I. Patient Information II. IndividualOrganization Authorized to Release (California)

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Completed 9 January 2022

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